A Lawyer's Perspective: Quality Care Programs Based on Objective Quality Indicators for the Strategic Purpose of Reducing Bedsores in Nursing Home Residents and Hospital Patients
We have written numerous blogs concerning the development of decubitis ulcers, commonly known as bedsores, due to the negligent treatment of the nursing home resident or hospital patient by staff members. One blog suggested using a quality-control approach to reducing the possibility of pressure ulcers. In this blog, we will revisit the concept of objective quality care approaches as a valid means of reducing: 1) the incidence of bedsores in the first place and/or 2) reducing the possibility of developing particularly serious Stage III (associated with open sores) and Stage IV (associated with craters or holes) bedsores.
This blog is intended to emphasize that: 1) the causes of bedsore development are known; 2) the risk factors for developing bedsores are known; and 3) steps/procedures which will help reduce the development of bedsores or at the very lease allow for early “treatment” intervention are well known. The above prevention tactics are nothing more than common-sense procedures that every nursing home and hospital can implement via specific quality care programs which are actually followed. That this blog contains references to Dr. Deming is due to the fact that one of the authors, prior to attending law school, was involved in product development in the medical device industry for an international medical device manufacturing company where product development was carried out through product development teams consisting of members ranging from R&D to regulatory affairs. The teams’ responsibilities included the establishment of objective quality assurance indicators. As discussed below, the authors believe that Dr. Deming’s principles are applicable to hospital and nursing home settings for reducing the development of bedsores.
As the name suggests, pressure sores result when the weight of the person’s body presses against a firm surface such as a bed mattress or a chair. Or put another way, the bed sores develop due to the pressure exerted by the bed or chair on the person’s body. In understanding just how such pressure cause bedsores, remember that the skin contains hundreds of blood vessels. Bedsore occur when the pressure cuts off the skin’s blood supply to the "pressure-contact" area. This area of damaged skin will become more susceptible to pressure-induced damage if steps are not taken to relieve/reduce pressure on the now-compromised skin. (Reference #2)
It should not be surprising that the elderly, who are often frail due to poor bone and skin integrity, are particularly susceptible to pressure sores because of their lower tissue tolerance for pressure. Old age is thus a “no brainer” risk factor for developing bedsores. Yet, many other well-known risk factors are associated with the development of pressure sores. Obviously the greater the number of risk factors specific to the person, the greater the likelihood that the person will develop bedsores. Besides old age, the following factors are known to increase the risk for developing pressure sores:
• Being bedridden
• Spending considerable time in a wheelchair
• Diabetes or vascular disease that prevents areas of the body from receiving proper blood flow
• Spinal cord injury (paralysis), brain injury, or other physical condition which prevents the person from moving parts of his/her body without assistance.
• Malnourishment
• Mental disability such as Alzheimer’s disease or dementia which may prevent the patient from moving parts of his/her body without assistance not necessarily because they are unable to do so, but because they are not aware that then need to do so
• Urinary incontinence or bowel incontinence (Reference #1).
Many of the listed risk factors are typically associated with old age; therefore most elderly persons have multiple risk factors ranging from confinement to bed and wheelchairs to incontinence, mental disability, and/or malnutrition. Upon their admission to a nursing home or hospital, elderly persons should thus undergo a formal risk factor assessment to determine their risk of developing bedsores. They should then be monitored carefully for the onset of bedsores so that treatment can be timely rendered while the bedsore is still at a readily treatable stage.
Unfortunately, failure of nursing home staff members and administrators to actively take measures to minimize the onset of bedsores and/or initiate prompt medical intervention can result in dire consequences for the “bedsore” patient, especially where Stage III and Stage IV bedsores are at issue. Obviously, nursing home patients confined to their beds should be turned frequently to “spread out” the pressure from the hard surface across a large area of the person’s body. The medical literature suggests that turning should occur every two hours. Nor should residents be allowed to sit for hours on end in a wheel chair without pillows or other means to reduce pressure points between their skin and the chair itself.
Pressure sores may also result if the bed-ridden elderly person is dragged or slid across bed sheets, thereby creating potentially harmful frictional forces between the person’s skin and the bed sheet. (Reference 2). It is also conceivable that “dragging” an elderly frail person may result in injuries to muscles or bones quite apart from bedsores. Such treatment may also constitute abuse. Nursing home patients are entitled to respectful, gentle treatment to prevent injuries, and it is up to the administrators to ensure that the residents are treated appropriately.
Another known risk factor involves incontinence. Failure to frequently change the underwear of individuals who are incontinent may increase the risk of developing bedsores; the resultant wetness from bodily waste can make the skin too soft and more likely to be injured by pressure.
Diabetes and hyperglycemia are two other well known risk factors for bedsores. One would hope that any nursing home resident or hospital patient who is known to be diabetic or hyperglycemic would receive a “heightened scrutiny” type of monitoring for bedsores from the onset of his or her hospitalization or residence at a nursing home.
Bedsores are generally associated with nursing homes. It must be emphasized, however, that bedsores do not only originate in nursing homes. Elderly people who are hospitalized also have a high risk of developing bedsores due to the various risk factors which make them susceptible to bedsores. Patients transferred from hospitals to nursing home rehabilitation centers or being returned to their previous nursing home residences, are particularly vulnerable to bedsores according to the statistics. It has been estimated that at least 10% and upwards of 35% of individuals transferred from hospitals to nursing home rehabilitation centers or the nursing home where they had previously resided prior to hospitalization already have bedsores at the time of admission. (Reference #4). Nursing homes should thus make every effort to carefully check any patient being transferred to the nursing home for bedsores at the time of admission. Without proper medical care, even minor bedsores originating at the hospital may “turn into” serious Stage III and Stage IV bedsores.
We further emphasize that pressure sores are not merely a condition of the elderly. Individuals suffering from conditions which prevent movement such as paralysis, severe arthritis and/or multiple sclerosis, are susceptible to bedsores because of their inability to move without assistance. Recently, Eric Trainor, a 30-year-old New York State resident, was awarded $2.2 million by a jury for the pain and suffering caused by horrific bedsores. As a consequence of a motor vehicle accident in which he had been a passenger, the Mr. Trainor had been hospitalized at Westchester Medical Center. His injuries had caused him to become a quadriplegic. Because of the hospital’s failure to turn the injured patient every two hours during his 6 week stay, the patient developed Stage IV bedsores which had to be surgically closed. Furthermore, as a consequence of the bedsores, the injured man had to refrain from participating in physical rehabilitation so much so that he lost the chance to build up his upper body strength.
As nursing home negligence and abuse attorneys, we are particularly offended by those situations where the and/or hospital nursing home facility knew or should have known of the bedsore(s) and failed to secure proper medical care before the bedsores turned into Stage III or Stage IV bedsores. As discussed above, the risk factors associated with bedsore formation are well known. One would hope that somewhere along the chain of command in nursing homes and hospitals that supervisory oversight would kick sooner rather than later to ensure that: 1) that basic procedures for reducing the formation of bedsores are in place, at the very least for those individuals who have multiple risk factors for developing bedsores; and 2) pressure sores are “caught” in their early stages.
We also hear the argument that bedsore prevention procedures would “break the bank” so to speak. This assertion is disingenuous, however, because it has been estimating that the price of managing a single serious pressure ulcer is as much as $70,000.00 and US expenditures for treating pressure ulcers have been estimated at $11 billion per year. (Reference No. 3). In general, elderly persons tend to heal more slowly from any type of injury because aging is associated with a decrease in the repaid rate of cells. (Reference No. 4). And its Medicare or the elderly resident’s Medicare HMO which is picking up the treatment cost, generally rendered by a wound care specialist, for all individuals 65 years old and over.
The foregoing begs the following question: If the reasons for bedsores are well-established, why haven’t many hospitals and nursing homes initiated quality care programs to minimize bedsores? Most hospitals and nursing homes at least give lip service to quality medical care by having a mission statement. But a mission statement in and of itself does not guarantee quality care. Quality can be an elusive concept if the “quality purveyor of medical care” cannot objectively define what constitutes quality care according to defined measurable parameters. As discussed in a previous blog, perhaps it’s time that medical facilities and nursing homes read up on Deming, the “godfather” behind the concept that reliable quality control procedures can actually increase the bottom line for manufacturing companies. (Reference No. 5). For medical care providers, the “quality control” procedures would of course be “quality care” procedures.
Interestingly, the American Nurses Association has articulated that the maintenance of skin integrity in hospitalized patients as an important indicator of quality nursing care “based on the premise that pressure ulcers are preventable.” (Reference No. 4). This is the type of measurable parameter that can be assessed in both hospitals and nursing homes. Furthermore, this type of objective quality care indicator is the type of ascertainable data we had in mind when we discussed the “Deming-like” approach to assessing cost effective steps for minimizing bedsores in nursing homes in a previous blog.
As stated above, surgery is known to be a risk factor for the development of bedsores, and patients undergoing cardiac surgery “have been identified as being at higher risk that surgical patients overall.” (Reference No. 4). In a journal article entitled “Prevention and Early Detection of Pressure Ulcers in Patients Undergoing Cardiac Surgery” by D. Sewchuck, C. Padula, and E. Osbourne published in AORN on July 2006, the authors discussed the results of a study to assess strategies for minimizing pressure sores in patients undergoing cardiac surgery. The authors cited the results of a study in which it was found that over half of the total pressure ulcers which occur in hospitalized patients occur in patients who have under gone surgery and that most of these were found in cardiac surgery patients. (Reference No. 4).
The authors further noted that cardiac surgery patients are probably already at a high risk of developing pressure sores in the first place because of the presence of diabetes, advanced age, and/or several comorbidities. Also, the nature of the cardiac surgery itself is a risk factor. Thus, a patient who is “bypass” will generally be confined to an operating room bed for an extended period of time, and “during the intraoperative period in particular, patients are often supine and cannot be turned.” (Reference No. 4).
Based on the results of their study, the authors concluded that “[m]easures which can be implemented in the OR [for reducing bedsores] should be considered.” These measures may include reducing the number of layers of material and assessing warming methods. The authors went on to make several recommendations for nurses who provide postoperative care to cardiac surgery patients. The recommendations are important because they are based on a common sense approach to understanding the patient’s risk for developing bedsores based on identified risk factors and taking actions to reduce the likelihood of bedsores based on the known risk factors. In particular, the authors emphasized that “an interdisciplinary, collaborative approach is critical” for developing a bedsore ulcer prevention strategy. In other words, a hospital’s bedsore prevention strategy will never be successfully implemented absent a team effort from the top down. (Reference No. 4).
Interestingly, Dr. Deming himself was an advocate of a multi-disciplinary team approach to both new product development and product performance issues within an organization to improve quality, develop products that meet pre-defined and achievable specifications consistent with customer requirements; and reduce product performance problems once the product is in the customers’ hands.
Sewchuk's, et al.'s own conclusions certainly argue in favor of the implication that the teamwork concept for promoting quality nursing care is indeed transferable to the hospital setting. Thus as a “high bedsore risk” risk, a cardiac patient’s hospital care team might consist of the bedsore risk assessor, a dietician knowledgeable in bedsore-related nutrition issues, the pre-operative nursing staff, and the post-operative nursing staff.
We applaud the American Nurses Association for “studying” bedsore prevention approaches in a hospital setting based on known risk factors. Serious bedsore development should not be treated as an expected outcome of hospitalization or nursing home confinement. That is, bedsores should not be treated as “collateral damage” of nursing home confinement where the residents, given their various risk factors, are ripe candidates for bedsore development. The same applies to hospital patients.
Bedsores may never be totally preventable, particularly in those nursing home residents who are often frail to start with and often have other risk factors such as diabetes and poor nutrition resulting from eating problems. Nevertheless, it would seem that any nursing home facility which has as its elderly persons as it customers should have in place procedures to, at the very least “catch” bedsores at a very early stage so that proper treatment can be timely rendered. Ditto for hospitals.
The successful implementation of a quality care program to reduce bedsores will require dedication from top management on down to create an environment dedicated to bedsore prevention and/or early intervention in treatment. This is not a situation where the wheel needs to be re-invented to achieve a desirable outcome. As discussed above, the risk factors associated with bedsore development are well known. Furthermore procedures for minimizing bedsore formation are well known. Nevertheless, knowledge without action is not going to solve bedsore problems.
It is our belief that any sustainable quality control program must include proper training of staff members and holding staff members and their supervisors accountable for lapses in the program. On the flip side, the institution could also encourage proper treatment of patients or residents by implementing an awards recognition program for those departments showing a genuine decline in the number of bedsore incidents due to the implementation of a quality control program. Management studies have repeatedly shown that employee motivation can play a key role in creating an atmosphere dedicated to quality control and also in retaining good employees. One well known way of motivating employees is through an employee recognition program because employees based on achievement of pre-defined quality care indicators.
Two possible objective quality care indicators are:
1. Bedsores per patient or per resident before and after implementation of a specific quality care program or modifications to an existing program. Objective indicator: a reduction in the percentage of patients who develop bedsores within a defined population of patients or residents.
2. Bedsore stage at which treatment commenced. Objective indicator: an increase in the percentage of patients who receive treatment at the readily treatable Stage I stage and a decrease in the percentage of patients who develop Stage III and Stage IV bedsores.
As stated above, procedures for minimizing bedsores are well known, and it is often the failure to follow these procedures which result in bedsores often because of improper training; lack of employee accountability; and/or lack of supervisory. These procedures include changing positions often. (Reference 2) Unfortunately many elderly nursing home residents do not have the strength to turn themselves and require assistance. Moreover, those residents suffering from dementia or Alzheimer’s probably lack the cognitive ability to “know” to turn themselves. Nursing homes and hospitals should have a policy whereby staff members turn their bedridden residents/patients every two hours and staff members should be required to document their actions.
Other prevention tactics include: 1) keeping the incline of the head of the resident’s bed less than 30 degrees; 2) supporting the resident’s legs correctly; 3) keeping the resident’s knees and ankles from touching by using a pillow under the legs from the middle of the calf to the ankle; 4) keeping the skin clean and dry; and 5) daily skin inspections. (Reference 2). The latter means actually evaluating the areas most susceptible to bedsores, namely the buttocks, hips, elbows, lower back, legs, and heels. (Reference 2).
Prolonged sitting in wheel chairs can present problems for the elderly resident who is either physically or cognitively unable to adjust his/her position. It has been recommended that the caregiver manually change the elderly person’s position every 15 minutes or so. (Reference 2). Such a recommended position-change schedule (4 times per hour) may be difficult to achieve in a busy nursing home on a routine basis. At the very least, the wheelchairs should have cushions that reduce pressure and provide maximum support and comfort. (Reference 2).
Nursing homes might also consider providing pressure-release wheelchairs for their residents, which tilt to redistribute pressure and may make sitting long periods easier and more comfortable and beds which have been shown to reduce the likelihood that a pressure ulcer will form. (Reference 2). Such seating and bed arrangements could at least be provided to those residents which are deemed to have a high risk of developing bedsores based on multiple risk factors as identified by the nursing home patient or hospital assessment team.
Other prevention tactics include using pressure-reducing beds, proper nutrition, and keen supervisory oversight. To borrow from former president Harry Truman, the buck will need to stop with upper management and supervisors and managers who must be the moral trend setters to create an atmosphere dedicated to minimizing pressure sores in nursing home residents and hospital patients. As discussed above, many of the procedures which are known to help reduce bedsores involve “hands on participation” by staff members and not additional equipment. At the very least, any patient who evidences signs of a Stage I bedsore needs to be treated promptly and such treatment can only be rendered if the staff is pro-active in monitoring its patients or residents.
The cost of doing something may be deemed unreasonable just based on dollars and cents. In fact any impact on dollars and cents may not be an immediate outcome of any implemented quality carel program. If, however, the pain and suffering of bedsore victims is taken into account, the cost of doing something should seemingly be a deemed a reasonable expense by of any hospital or nursing home which truly cares about its patients and residents. Even taking “baby” steps towards a lofty goal such as reducing bedsores are preferable to doing nothing. It should be noted that medical providers themselves have opined that the Deming philosophy is applicable to their profession. Reference #6.
Unfortunately, we are not optimistic that nursing home negligence and abuse and hospital negligence will become a problem of the past any time soon. Bedsore victims do have the legal right to seek damages for their pain and suffering from nursing homes, and we would state that this right to sue is intended by state legislatures to “encourage” medical providers and nursing homes to provide decent care to its patients/residents. In fact, Florida has Nursing Home Bill of Rights which provides bedsore victims with a right to initiate legal action. If the bedsores become so serious that they contributed to the person’s death, the victim’s estate may commence a wrongful death action.
A bedsore case attributable to hospital neglect, even if involving the nursing staff only, must be brought as a medical malpractice lawsuit. However, unlike other "med mal" actions in Florida, standing is enlarged to include family members for their own pain and suffering. If the bedsores cause or are the partial causes of a wrongful death, standing embraces family members other than the widow, widower and/or surviving children under the age of 25.
We hope the above discussion was informative. If you or a loved one have suffered from bedsores resulting from hospitalization and/or a nursing home, particularly from bedsores which were allowed to worsen before treatment was commenced, you may wish to consult with an attorney to discuss your options.
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Reference #1. Electronic publication by the National Institutes of Health. Available at www.nlm.nih.gov/medlineplus/ency/article/007071.htm
Reference #2. Electronic publication by the Mayo Clinic www.mayoclinic.com/health/bedsores/DS00570.METHOD=print&DSECTION= all
Reference #3. Preventing Pressure Ulcers: a Systematic Review by Madhuri Reddy, MD; Sudeep S. Gill, M.D.; and Paula A. Rochon, MD in the Journal of the Medidcal Association (JAMA), vol. 2006 No. 8, August 23/30, 2006.
Reference No. 4: Prevention and early Detection of Pressure Ulcers in Patients Undergoing Cardiac Surgery by Dennis Sewchuk, Cynthia Padula, and Evelyn Osborne in AORN J.
See also Patient Risk Factors for Pressure Ulcers During Cardiac Surgery by Linda Lewiski, Lorraine Mion, Karen Splane, Doris Samstag, and Michelle Secic, AORN J. vol. 65, pp 933-42 (May 1997).
Reference #5. Electronic publication by Aetna. available at www.intelihealth.com/IH/ihtIH/W/9339/10914.html
Reference #6. Teamwork, Quality, and Competitive Advantage: the Deming philosophy in orthodontics. J. Clin. Orthod. vol. 27, pp 269-75 (May 1997).
